Losing the Louse: How to Manage this Common Infestation in Children

Vicky R. Bowden, DNSc, RN


Pediatr Nurs. 2012;38(5):253-254. 

In This Article


Treatment for lice can be completed at home and involves applying a pediculicidal agent, removing nits, and thoroughly cleaning (delousing) the environment. All three steps are critical to preventing recurrence. All potentially exposed persons should be examined and treated if infested. School and daycare settings are susceptible environments for the transmission of lice due to the close proximity of children and the frequency with which they have physical contact with each other and their personal items.

Pediculicidal Agents

Pediculicidal agents include permethrin 1% (preferred agent) and pyrethrins; common brand names include Kwell®, Nix®, Rid®, and Pronto®. A 1% lindane shampoo can also be used to treat resistant head lice; however, lindane use is controversial because of concerns about neurotoxicity and is only available by prescription. Malathion (Ovide®) has been shown to kill both nonresistant and resistant lice, and is available by prescription. Malathion may cause respiratory depression if ingested and should not be used on neonates and infants, and its safety in nursing mothers and children younger than 6 years is uncertain (Flinders & De Schwenitz, 2004; Frankowski, Weiner, & the Com mittee on School Health and Com mittee on Infectious Diseases, 2002). Malathion should be considered for use only when other agents have failed. An expected side effect of these topical agents is itching and burning of the scalp or skin area where the ointment is applied. The FDA now requires the labeling for malathion to include information about the side effects of the stinging sensation and the potential for chemical burns, in cluding seconddegree burns (Mississippi Division of Medicaid, 2012). If burning and itching persists for several days, corticosteroids and oral antihistamines may be ordered to help relive these symptoms.

Newer treatment products include spinosad 0.9% (Natroba®) and benzyl alcohol 5% (Ulesfia® Lotion). Spinosad is a topical agent approved by the FDA in 2011 to treat children 4 years of age or older (Brown & Rowland, 2012). This product is both a pediculicide and an ovicide, killing both the lice and the nits. This eliminates the need for extensive combing of the hair to get rid of the nits. The product is applied to dry hair and washed off with water after 10 minutes. Repeat application, though not generally needed, may be done 7 days later if live lice are seen. Brown and Rowland (2012) share concerns that the cost may be prohibitive to many families – "the average cost of an application of permethrin 1% is about $20; an application of spinosad costs $270 without insurance" (p. 42). Ulesfia Lotion is approved for patients 6 months of age or older. Similar to spinosad, the lotion is also applied to dry hair and rinsed off within 10 minutes. However, re-application is required in 7 days. Both spinosad and Ulesfia Lotion contain benzyl alcohol and have serious side effects (including death) when applied to children younger than 6 months of age (Mississippi Division of Medicaid, 2012).

When teaching parents about pediculicide treatment, emphasize that more is not better. Directions for application must be strictly followed. Repeat the application in 7 to 10 days if live lice are present. Overuse and misuse may lead to absorption into the bloodstream and the possibility of adverse effects. The child's eyes must be carefully protected, and the parent should wear rubber gloves. Pediculicides cannot be used on eyebrows or eyelashes because they are irritating. Rather, lice infestation in these areas is treated by applying petrolatum to the lashes and brows three to four times a day for 2 weeks. The petrolatum seems to suffocate the insects. The nits can then be removed with a fine-toothed comb or tweezers. Infestation in infants should never be treated with pediculicidal products. Rather, the lice and nits should be manually removed or hand combed. Pregnant women and persons allergic to pediculicidal agents should never apply treatment with these agents. Parents should be warned to avoid treating lice infestation with home remedies. Dog shampoo, vinegar, and kerosene have not been clinically proven to be effective against lice (Frankowski et al., 2002).

After the child is treated for lice, parents should contact a health care provider if the child's itching interferes with sleep or the rash is not cleared within one week after treatment. Further, if the rash or sores begin to look reddened, are warm to the touch, or are oozing secretions, or if the child develops a fever, the health care provider should be called. Most importantly, the child should be assessed 7 to 10 days after treatment to ensure no new nits have appeared.

Removing Nits

Nit removal, while tedious and time-consuming, is absolutely necessary. None of the pediculicides are 100% ovicidal (effective in killing all lice). Therefore, manual removal of nits after treatment with a pediculicide is recommended (Madke & Khopkar, 2012).

To remove the nits, divide the child's towel-dried hair (not sopping wet) into four parts and insert a finetooth comb at the top of the head first. If nits fall into the lower hair, they will be removed with combing of the inferior areas. Two types of combs are available – those with plastic teeth and those with metal teeth. Metal combs come in two varieties – those made from a flat sheet of metal and have rectangular teeth, and those that have cylindrical teeth embedded in a plastic base (Speare, Canyon, Cahill, & Thomas, 2007). The Lice Meister® is a metal comb recommended by the National Pediculosis Association (2011) that had demonstrated efficacy for nit removal over a plastic-tooth comb in one study (Speare et al., 2007).

Check the heads of everyone else in the home, school, or daycare, and treat any scalp rashes, sores, or itching with the anti-lice shampoo. Children can return to school after one treatment with the shampoo or medicine.

Delousing the Environment

The environment must be thoroughly cleaned because transmission occurs from direct contact (body to body, hair to hair) or indirect contact (clothing, brushes, and hair apparel). Lice cannot live more than 48–72 hours off the human body. Therefore, the house should be vacuumed thoroughly, combs and brushes should be soaked in antilice shampoo, and all clothing and sheets should be washed in hot water (see Figure 1).

Figure 1.

Effective Delousing of the Environment

To prevent lice infestations at daycare and school settings, encourage teachers, parents, and care providers to do the following:

  • Have carpeted areas frequently vacuumed.

  • Discourage body contact and sharing of personal items between children (for example, hats, coats, combs, and similar personal items).

  • Remove from the classroom items (such as costumes, pillows, and blankets) that may be shared or used during playtime by numerous children.

  • Know how to examine for and identify lice.

  • Notify the nurse if a case is found.

  • Store naptime supplies in a clean area and send them home for frequent cleaning.

  • Have student clothes-storage areas (lockers) separated adequately by space and not be shared.

  • Check the child's head after attending a sleepover or camp where children may share sleeping areas.